a cognitive behavioral treatment manual for body dysmorphic disorder

a cognitive behavioral treatment manual for body dysmorphic disorder

Abstract There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory-II were completed pre-treatment, monthly, post-treatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Despite the prevalence and morbidity associated with BDD, treatment research on BDD is scarce. These preliminary studies were promising; however, conclusions about the generalizability and replicability of their results are limited by the small number of studies, small sample sizes, and restrictive inclusion criteria (see Wilhelm et al., 2011, for review). Moreover, most prior studies of CBT did not report on medication use during treatment. Treatment manuals allow for standardized dissemination of a new treatment. Thus, the lack of a widely applicable and tested CBT manual for BDD has been a major limitation for the field. CBT-BDD utilizes standard core elements relevant to all BDD patients, plus optional modules used as needed. Core treatment elements include psychoeducation, cognitive interventions (e.g., to address maladaptive beliefs related to BDD, the importance of appearance or self-worth), exposure to avoided situations and prevention of rituals, and mindfulness and perceptual retraining (e.g., to reduce selective attention to details such as appearance flaws). Optional treatment modules are provided to flexibly tailor treatment to address symptoms that affect some but not all patients (e.g., skin picking, surgery seeking). For all patients, treatment ends with relapse prevention strategies and booster sessions focused on helping patients maintain their gains.http://www.oglethorpeclub.org/~oglethor/UserFiles/bosch-psr-2_4v-manual.xml

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The use of broader inclusion criteria than most prior CBT studies increased the sample’s representativeness. The 2011 Wilhelm et al.In intent-to-treat (ITT) analyses, BDD symptoms and depressive symptoms improved significantly at post-treatment. Seventy-five percent of the ITT sample were treatment responders (i.e., had at least a 30% reduction in BDD-symptom severity over the course of treatment), as were 80% of the completer sample. Treatment gains were maintained at the six-month follow-up assessment. While these preliminary results were encouraging, they must be interpreted with caution, as there was no comparison condition to control for other factors potentially related to improvement, such as the passage of time. Further, because only expert therapists treated patients in this initial trial, it was unclear whether CBT-BDD could be successfully administered by less experienced clinicians. In the current study, we evaluated the efficacy of CBT-BDD in a randomized trial with a waitlist control, a reasonable comparison group to test a newly manualized treatment. Although this design does not provide definitive evidence for efficacy, it allows determination of whether active treatment is superior to gains that would be observed simply due to the passage of time or other confounding variables (e.g., history, maturation, testing). We hypothesized that CBT-BDD would be more efficacious for BDD than the waitlist condition. Because BDD is associated with substantial impairment and morbidity, we also investigated whether participants who received immediate CBT-BDD relative to those in the waitlist condition would experience improved functioning. We also examined treatment feasibility and acceptability, and whether CBT-BDD could be delivered successfully by non-expert therapists. Method Participants Participants consisted of 36 adults (61% female) age 18 or older with primary DSM-IV BDD (based on symptom severity).http://www.bresky.cz/res/bosch-psr-1440-manual.xml

Potential participants were screened initially by phone for BDD and were invited for an in-person assessment if they met eligibility criteria. Participants were recruited with flyers and brochures posted in the community and mailed to clinicians (e.g., mental health professionals, dermatologists, plastic surgeons) in the surrounding areas from August 2005 to December 2008. We included participants taking psychotropic medication if they reported a stable dose for at least two months prior to the initial evaluation and agreed to not change their medication during the study. Procedures and Allocation Strategy A total of 44 individuals (24 from Massachusetts General Hospital and 20 from Butler Hospital) signed consent forms and were enrolled in the study. Prior to randomization, eight participants were excluded: seven were ineligible (two had unstable doses of medication, two had symptoms that were too mild, one was already in psychotherapy, one had a substance use disorder, and one did not have BDD as the primary diagnosis), and one participant declined to participate in treatment. We randomized the remaining 36 participants to one of two conditions: immediate CBT-BDD or 12-week waitlist control. Thus, to control for these variables we stratified our randomization by delusionality and current depression. Of the 36 participants, 17 (9 females) were randomized to 12 weeks of immediate CBT-BDD, and 19 (13 females) were randomized to 12 weeks of waitlist 1. We limited the duration of the waitlist to 12 weeks as it seemed ethically problematic to ask very ill individuals (including those who were passively suicidal, i.e., had thoughts of killing themselves but had no plans of acting on those thoughts) and were eager to start treatment to wait more than 3 months. After the first 12 weeks of the study, CBT-BDD participants continued on to complete the remainder of the 22-session treatment, whereas waitlist participants were crossed over to 22 sessions of CBT-BDD.

Audiotaped therapy sessions were rated by an independent doctoral-level psychologist for fidelity and quality. Adherence to session structure and session content was rated on a 7-point scale ranging from 1 ( not at all adherent ) to 7 ( completely adherent ). Competence was rated on a 5-point scale ranging from 1 ( not at all competent ) to 5 ( completely competent ). (Adherence and competence forms are available upon request from the authors.) Our protocol also specified procedures for retraining or replacing any therapist who had recurrent difficulties meeting adherence and competence requirements, but we did not encounter these difficulties in the study. Twenty-percent of sessions were randomly selected. This study had two independent evaluators, and tapes from both interviewers were rated. Inter-rater reliability, calculated via intraclass correlations between independent ratings, for the BDD-YBOCS was.93 (p Measures Interested study candidates who called our programs were first screened by highly trained bachelors level research assistants. Those who appeared eligible on the phone screen were scheduled for an in-person assessment. A full-scale IQ score was estimated with the WASI Vocabulary and Matrix Reasoning subtests ( Wechsler, 1999 ) to assess cognitive impairment. Those deemed eligible were scheduled for a baseline visit and randomized to immediate CBT-BDD or to waitlist. Follow-up assessments were performed 3- and 6-months after treatment cessation. Participants allocated to waitlist had assessments at baseline and at weeks 4, 8, and 12 before receiving 24 weeks of CBT-BDD. Participants completed self-report questionnaires and participated in semi-structured interviews conducted by a doctoral-level independent evaluator who was blind to treatment condition. The BDD-YBOCS was administered at baseline, monthly during treatment, at week 24 (post-treatment), and at follow-up. The Brown Assessment of Beliefs Scale (BABS; Eisen et al.

, 1998 ) is a valid, reliable 7-item interview that dimensionally measures insight regarding inaccurate beliefs (e.g., “I look like a hideous monster”). Specifically, participants endorse their agreement with 21 items reflecting DSM-IV criteria for major depression. The SDS was administered at baseline, week 12, week 24 (post-treatment), and at follow-up. The CSI was administered monthly during treatment and at week 24 (post-treatment). In addition, patients practiced shifting their attention away from their perceived flaws to characteristics of others (appearance and non-appearance related) and to the task at hand (e.g., towards a conversation). Advanced cognitive restructuring helped patients learn to modify deeply held core beliefs (e.g., “I am unlovable”) and included interventions to decrease the importance of appearance and help patients to base their self-esteem on other aspects of themselves (e.g., being a good friend). Relapse prevention focused on consolidation of skills and maintenance of gains. Usually a therapist would select specialized modules after the patient had been introduced to all core CBT-BDD skills. In sessions when modular interventions were used, they were employed instead of continued work on core treatment components (and therefore the use of modular strategies did not alter the length of therapy). Treatment was delivered by advanced graduate students and post-doctoral-level psychologists with a basic knowledge of BDD. Therapists received rigorous training in the study protocol and were supervised weekly by Dr. Wilhelm. Individual therapy sessions lasted 60 minutes. Sessions were scheduled once weekly except that the last two sessions (relapse prevention) were spaced two weeks apart. We also examined factors associated with early termination. For each measure analyzed, we conducted three sets of efficacy analyses: (1) CBT-BDD vs.

In the week 12 analyses, we compared change in outcome over the first 12 weeks by randomized treatment group (immediate CBT-BDD vs.Random slopes models have the benefit of including in the analysis all participants who contributed any data, even those who dropped out immediately after baseline. Random effects were included for both slope and intercept. An unstructured covariance was used if possible, and otherwise covariance structures were tested to find the best fit to the observed data. Linearity of each outcome with respect to week was verified through visual inspection of graphs and likelihood ratio tests. For the SDS (which was not administered monthly), Student’s t-test was used to compare the change in total score from baseline to week 12 between the treatment groups. The second set of analyses examined efficacy of 24 weeks of CBT-BDD by comparing the rate of change of each measure with a null change in the combined sample of immediate CBT-BDD and waitlist participants subsequently crossed over to CBT-BDD (for whom assessments made prior to crossing over to CBT-BDD were excluded). These analyses employed random slopes models with a term for week, whose parameter estimate was compared to 0. We also examined whether the effect of CBT-BDD on BDD-YBOCS total score over time differed by original randomized treatment assignment. For the SDS, we used Student’s t-test to determine whether the difference between baseline and week 24 (or week 12 if the patient terminated early) differed significantly from a null change. The third set of analyses used Student’s t-tests to determine whether the change from week 24 (post-treatment) to follow-up month 6 (or follow-up month 3 if the patient was lost to follow-up) differed significantly from a null change. We averaged ratings for therapist adherence to CBT-BDD session structure and content and for therapist competence. We also calculated the Client Satisfaction Inventory (CSI) percent of total score at post-treatment.

For comparison with other studies, we calculated effect sizes (Cohen’s d ) for each outcome ( Cohen, 1988 ), based on a t-test with pooled variance. Participants who terminated the study immediately after baseline (for week 12 analyses) or during the waitlist (for week 24 analyses in the combined sample) were included in analyses that employed random effects modeling, but were excluded from analyses employing t-tests to examine change from baseline onwards (e.g., analyses of response and of the SDS). Per the protocol for this study, significance was based on a two-sided alpha of 0.05 in the primary and secondary analyses of this pilot trial to avoid inflating the type II error rate and to control the type I error rate ( Feise, 2002 ). However, to properly communicate the level of significance of each result, we have reported the precise p-values out to two significant digits (unless Results Descriptive Characteristics at Study Baseline Baseline characteristics including demographics, medication use, and comorbidity for the CBT-BDD and waitlist groups are presented in Table 1. No significant differences were detected in baseline characteristics between the waitlist and immediate CBT-BDD groups. No significant differences between the groups were detected in baseline characteristics. Figure 1 shows the flow of participants through the study. Seven (19%) participants (3 immediate CBT-BDD, 4 waitlist) terminated from the study early. In the immediate CBT-BDD group, one dropped because the study became too much of a time commitment after a death in the family, one moved out of the country, and the third was withdrawn because of a medication dosage change. Of the waitlist patients, one was withdrawn due to assessment noncompliance, and one dropped because the patient could not manage the time commitment due to starting a new job.

Two waitlist patients dropped after crossing over to CBT-BDD: one prior to starting treatment as she felt that outpatient treatment was insufficient to treat her symptoms, and one because travel to the study site was too burdensome (a one-way trip took about 2-3 hours). Effect of CBT-BDD vs. Results were similar among the 31 participants who completed all assessments through week 12. Waitlist) or during the waitlist (Week 24 combined sample) assessments.The effects of 24 weeks of treatment are also shown in Table 2. During six months of follow-up, the magnitude of changes in secondary measures were minimal (less than a one-point difference, on average, as seen in Table 2 ), and no clinically or statistically significant differences were detected between post-treatment and 6-month follow-up, indicating that participants maintained their treatment gains. Treatment Feasibility and Acceptability CBT-BDD proved feasible to deliver by non-expert therapists who received regular supervision. Therapist competence and adherence were good among a random sample of 16 participants whose sessions were rated. This high satisfaction was reflected in comments such as: “This study has changed my life.” “The change in my life has been incredible.”“This treatment has helped me in 6 months in ways that years of other therapy have not.” No adverse events were reported. Discussion In this study, we examined the efficacy of CBT-BDD relative to a waitlist control condition in adults with BDD. Results from this study are consistent with prior research and advance the literature in several ways. Despite the fact that this sample included participants who were more severely ill at the beginning of treatment relative to previous studies, BDD-YBOCS total scores decreased by an average of 16.5 points over 22 sessions. The reduction in BDD-YBOCS scores was somewhat larger than that previously reported by Veale et al. (1996) for their 12-session individual treatment (11.25).

The BDD-YBOCS decrease in the current study was also larger than in Wilhelm et al.’s (1999) 12-week group treatment (9.6). Rosen et al. (1995) did not administer the BDD-YBOCS, but reported an 81.5% response rate in patients randomized to an 8-week CBT group treatment. While significance was achieved after excluding only a small number of participants (8% of the analysis population), we conservatively chose to retain these outliers in the main ITT analysis to improve the generalizability of our results. Still, it is important to consider that improvement on the BDD-YBOCS approximately doubled between week 12 and post-treatment, reflecting the potential benefits of three additional months of treatment. Thus, it is likely that we would have found differential effects of CBT-BDD and the waitlist comparison group if the controlled phase of trial had been longer than 12 weeks. Our findings suggest that CBT specifically developed for BDD also improves BDD-related insight and associated symptoms such as depression and disability. The seven (19%) participants who dropped out or were withdrawn early from the study had a higher BDD-YBOCS total score, a higher BDI-II total score, and were more likely to have a personality disorder than those who completed the study. This difference suggests that data from participants who terminated early may not have been missing at random (MAR), a necessary condition for the random slopes model estimates to be valid. However, the similarity of results in sensitivity analyses that excluded early terminators, and in analyses that controlled for drop-out, suggests that our findings are robust to the assumption of MAR. From a clinical perspective, it appears that those who terminated early were more severely ill. It might not have been tolerable for those who were suffering to this degree to comply with all of the study procedures (baseline and screening visits) and a delayed start of treatment.

The remaining three drop-outs dropped during CBT-BDD (1 at week 4 and 2 at week 8); we examined whether satisfaction with treatment might have been a factor related to drop out. One participant did not complete the CSI prior to dropping because the measure had not been administered yet, and the CSI scores for the remaining two patients (both collected at week 4) were relatively high (77.3% and 95.3% out of 100% total). Thus, while this study is small and available information is limited, it appears that dissatisfaction with treatment does not appear to be the primary reason for dropout, other reasons mentioned above appear to be more compelling (e.g., moving out of the area). Our predictors of early termination indicate that in future treatment studies special attention may be needed to retain participants with more severe BDD, more severe depression, and those with comorbid personality disorders. Taken together, we used a manualized modular treatment ( Wilhelm et al., 2013 ) delivered by new therapists, and measured treatment adherence and fidelity. Our results indicate that new therapists can learn how to administer, adhere to, and deliver this treatment competently. The promising results of our two-site design further suggest that CBT-BDD is an exportable treatment. However, although the therapists on our CBT-BDD study were novices, they not only reviewed the treatment manual but also received six hours of didactic training followed by weekly supervised casework with a CBT-BDD expert. This type of training and intensive supervision by experts will be difficult to replicate in community settings. But it is possible that successful therapist training in CBT-BDD might entail more than simply having therapists read the treatment manual. Thus, future research needs to explore the most beneficial methods CBT dissemination in general, and in particular those for CBT-BDD.

The incorporation of CBT-BDD in nationwide training efforts, such as the ones offered by the International Obsessive Compulsive Disorder Foundation for various obsessive-compulsive spectrum disorders, should be examined as well. One study limitation is the relatively small sample size, which limited statistical power (i.e., inflated type II error) at week 12 in analyses of change on continuous outcome measures. Thus, some caution is needed when attributing gains to CBT-BDD, and replication in a larger sample is clearly needed. As a next step, a more definitive test of CBT-BDD’s efficacy is required, and the full length (24-week) CBT-BDD should be tested against an alternative treatment (such as supportive psychotherapy) to control for nonspecific factors of therapy. We chose inclusion and exclusion criteria that were broader than those used in most previous studies of CBT for BDD, allowing for inclusion of individuals with delusional BDD beliefs (absent insight), and of both genders. Individuals with passive suicidal ideation were also included, but for safety reasons, we chose to exclude actively suicidal patients from the study. To address some comorbid features, such as more severe depression, the optional treatment modules that therapists could choose from allowed for some flexibility. However, future large scale studies should test the frequency with which the specific modules are employed. Future research is also needed to develop and test a CBT-BDD module for more highly suicidal patients. Although BDD typically onsets in adolescence and usually has a chronic unremitting course if untreated ( Phillips, Menard, et al., 2013 ), the adolescent treatment literature is scarce. Thus, future research will need to focus on the development and testing of CBT-BDD for adolescents. Thus, future research should explore relationship of changes in these symptoms.

In addition, future research is needed to explore the role of attention and interpretation biases, as well as maladaptive beliefs, as potential mediators of treatment outcome. Exploring possible mediators of treatment response in larger samples is expected to advance the understanding of processes that maintain BDD. In summary, CBT-BDD is a comprehensive, flexible treatment that is applicable to a broad range of patients and includes unique strategies to address symptoms (e.g., delusions of reference, perceptual distortions, surgery seeking, and self-injurious skin picking) that distinguish BDD from other disorders. The current study indicates that CBT-BDD is feasible, acceptable, and very promising, and that it warrants more rigorous investigation. Moreover, this new treatment, specifically developed for a complex and often-severe disorder, was successfully learned and delivered by novice therapists. Given that BDD is an understudied and common disorder for which efficacious treatment options are currently very limited, follow-up controlled studies that include larger samples and compare the efficacy of CBT-BDD to alternative treatment conditions are greatly needed. ?The authors wish to thank Kara Watts, Stefanie Renaud, Tracy Singer, Katherine Crowe, Irina Kasarskis, William Menard, Luana Marques, Sherrie Delinsky, Hillary Cerullo, Angela Stewart, Jennifer Ragan, and Natasha Hansen for their assistance in conducting this study. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Wilhelm, Phillips and Steketee report receiving royalties from Guilford Press for a treatment manual on body dysmorphic disorder (BDD).

In addition, we have the following disclosures, which are not directly relevant for this project. Drs. Wilhelm, Phillips, and Steketee receive royalties from Oxford University Press. Drs. Wilhelm and Steketee receive royalties from New Harbinger Publications. Drs. Wilhelm and Phillips receive support in the form of free medication and matching placebo from Forest Laboratories for a clinical trial funded by the National Institutes of Health. References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: 2000. Intensive cognitive-behavioral therapy for adolescents with body dysmorphic disorder. Body dysmorphic disorder: a review of conceptualizations, assessment, and treatment strategies. Characteristics of memory dysfunction in body dysmorphic disorder. The Brown Assessment of Beliefs Scale: reliability and validity. Insight in obsessive compulsive disorder and body dysmorphic disorder. Do multiple outcome measures require p-value adjustment. Failure in treating obsessive-compulsives. Cognitive-behavioral therapy for adolescent body dysmorphic disorder. Body dysmorphic disorder in an adolescent girl. Predictors of treatment outcome in the behavioural treatment of obsessive-compulsive disorder. The prevalence of body dysmorphic disorder in the United States adult population. Mediators and moderators of treatment effects in randomized clinical trials. Body dysmorphic disorder: a preliminary evaluation of treatment and maintenance using exposure with response prevention. The Client Satisfaction Inventory: Results of an initial validation study. Predictive validity of the overvalued ideas scale: outcome in obsessive-compulsive and body dysmorphic disorders. Psychosis in body dysmorphic disorder. Suicidal ideation and suicide attempts in body dysmorphic disorder. Gender differences in body dysmorphic disorder. Clinical features of body dysmorphic disorder in adolescents and adults.

A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. A four-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. The assessment of trichotillomania. The Anxiety Disease. We don’t train in vain: a dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. Dealing with missing data in a multi-question depression scale: a comparison of imputation methods. Ensuring balanced distribution of prognostic factors in treatment outcome research. Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial. An application of an urn model to the design of sequential controlled trials. A cognitive-behavioral treatment approach for body dysmorphic disorder. In: Frost RO, Steketee G, editors. Cognitive Approaches to Obsessions and Compulsions: Theory, Assessment and Treatment. The 13-digit and 10-digit formats both work. Please try again.Please try again.Used: GoodThe authors are experts on BDD and related conditions. They describe ways to engage patients who believe they have defects or flaws in their appearance. Provided are clear-cut strategies for helping patients overcome the self-defeating thoughts, impairments in functioning, and sometimes dangerous ritualistic behaviors that characterize BDD. Clinician-friendly features include step-by-step instructions for conducting each session and more than 50 reproducible handouts and forms; the large-size format facilitates photocopying. See also the related self-help guide by Dr. Wilhelm, Feeling Good about the Way You Look, an ideal recommendation for clients with BDD or less severe body image problems. Then you can start reading Kindle books on your smartphone, tablet, or computer - no Kindle device required.

In order to navigate out of this carousel please use your heading shortcut key to navigate to the next or previous heading. In order to navigate out of this carousel please use your heading shortcut key to navigate to the next or previous heading. Register a free business account Their systematic treatment is science based, clinically informed, and practitioner friendly. This book fills a critical niche by providing concrete, hands-on guidance for conducting state-of-the-art cognitive-behavioral therapy for BDD. The guidelines in this book will be accessible and useful for a wide range of readers, from students just beginning their training in behavioral therapies to seasoned professionals who are already experienced with BDD. The manual also provides a concise review of the scientific basis for the approach. This book encapsulates the wisdom from extensive clinical experience. The level of step-by-step detail that is provided on session structure and content make it a very useful guide for less experienced therapists, while the organizational clarity of the manual makes it an accessible reference resource for the more experienced therapist. One of the very nice features of the manual is the generous supply of clearly indexed questionnaires, information sheets and therapy forms for use in assessment and treatment.Dr. Wilhelm's clinical work and research focus on body dysmorphic disorder, OCD, and tic disorders. She is the author of more than 200 articles and book chapters and several books, including the self-help guide Feeling Good about the Way You Look: A Program for Overcoming Body Image Problems, which was cited as a Self-Help Book of Merit by the Association for Behavioral and Cognitive Therapies (ABCT). She is a Fellow of ABCT and the Association for Psychological Science. Katharine A.